COMMERCIAL PROPERTY/LIABILITY APPLICATION

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1 COMMERCIAL PROPERTY/LIABILITY APPLICATION APPLICANT Name of Insured: Mailing Address: Risk Address: Description of Operations Occupancy of Others of Year in Business Name(s) and Address(es) of Mortgagee(s) or Landlord(s) Existing Insurer: Policy No.: Expiry Date: Renewal Offered: If not, why not: Expiring Premium: Target Premium: Has the Insured ever been cancelled or declined? (If so, please attach details) Please provide details of all losses in past five (5) years: PROTECTION Distance to: fire hydrant? firehall? paid or volunteer? Are premises sprinklered? Percentage sprinklered? % of portable extinguishers? Type? Dimensions of safe? X X Class? Alarmed? How often are deposits made? By whom? ALARM DETAILS Local or Monitored? Monitoring Company? U.L.C. rated? Dedicated line? % of premises alarmed? FIRE BURGLARY PROPERTY QUESTIONNAIRE Building Construction: Original Building First Addition Second Addition Walls Roof Floors Year Built Type of Heating Ground Floor Area Fuses or Breakers Overfusing Occupancy First Floor Second Floor Third Floor Year of Plumbing Year of Wiring Year of Heating Year of Roof

2 EXPOSURES Construction Height Distance Right Left Front Rear LIABILITY QUESTIONNAIRE Total Square Footage Occupied by You By Others Total Annual Receipts (including cost of materials and labour) Type of Operations Last Year s Actual Receipts Estimated Receipts for this Year Receipts Split Canadian $ U.S. $ Other (specify) $ Are any operations performed in the United States? Yes No. If yes, give full details Are any operations performed outside Canada or the United States? Yes No. If yes, give full details Total of Employees of Employees not subject to Worker s Compensation Estimated Payroll: a) Clerical and Administration b) Salesmen (Inside and Outside) c) Manufacturing or Plant d) Installation or Erection e) Servicing f) Warehousing including Shipping Products (a) Estimated annual sales/receipts for each product manufactured, sold, handled or distributed by the Applicant Sales/Receipts Description of Product Canada United States Other (Specify) (b) Does Applicant manufacture the complete product? Yes No If no, what component parts are purchased by the Applicant? (c) Does the Applicant assemble the product? Yes No (d) Does the Applicant maintain and/or service the products? Yes No If so, state receipts from source $ Do any of Applicant s products require mixing, blending, altering, repacking or relabelling by others? Yes No If yes, state details (e) Are any of Applicant s products inflammable or explosive? Yes No If yes, state details (f) Are any of Applicant s products toxic or poisonous either by themselves or in combination with other materials? Yes No If yes, state details (g) Do any of these products Applicant now sells or ever has sold contain asbestos? Yes No If yes, state details (h) Does Applicant issue guarantees and/or warranties to purchasers? Yes No If yes, state details (i) Does Applicant agree to hold both dealers or distributors or suppliers harmless against claims or suits for personal injury or property damage in connection with Applicant s products? Yes No (j) Is product accompanied by any brochures, instructions, or other written statements? Yes No (k) Are Annual Reports and/or product brochures available? Yes No If yes, please attach.

3 (l) Does Applicant maintain quality control procedures? Yes No If yes, give brief outline of such procedures (m) Does Applicant maintain complete inventory records, shipment records and/or delivery records to consignees and are serial a/o batch numbers shown on the finished product and on shipment invoices? Yes No (n) Can the date of manufacture of each product be identified by factory number stamped on it? Yes No (o) Has Applicant ever recalled any products for any reason or been ordered to do so by any Government Authority? Yes No If yes, state details (p) Have any products been withdrawn or discontinued during the past five years? Yes No If yes, state details (q) What will be the end use of these products? Elevators (Owner or for which you are responsible by lease agreement) Type (passenger and/or freight) Independent Contractors (give estimated cost of work given to independent contractors) As owner of Building, repair and maintenance As a General Contractor or Contractor Others (Describe) Contractual Liability I Railway sidings, crossings or right of ways Give Name of Railway Company (s) II Other agreements whereby liability is assumed Give Nature Submit Copies of Agreements Special Premises or Operations Hazards (give description on separate sheet if necessary) A) Watercraft Owned or Chartered Type (Make/Model etc) of Watercraft Length Horsepower B) Private Docks or Wharfs C) Swimming Pool, Saunas, Gym & Other Recreational or Athletic Facility Type of Facility Size and Depth of Pool D) Private Road Mileage E) Mechanical Truck Loading or Unloading Facilities Describe F) Radioactive Material Nature Use G) of Aircraft Leased or Chartered During the Year Cost H) Give description and location of any dams, water stave lines, private railroads I) Give Percentage (%) of the Following Operations Blasting % Welding % Explosives % Wrecking/Demolition % Chemicals % Hot Tarring % Shoring/Underpinning % Gases % Natural Gas % Pile Driving % Liquified Petroleum % Pesticides % Logging % Radioactive Materials % Raising Structures % Excavation % Caisson Work % Moving Structures % Tunnelling % Asbestos % Describe in full detail of any of the above operations

4 Non-Owned Automobile (Give number of employees using their cars on Company business) Regularly Occassionally Accident Prevention and First Aid a) First Aid Posts Doctors Full Time Part Time Nurses Full Time Part Time b) Fire Alarm Other Warning Systems c) Is a Security Officer or Loss Prevention Engineers Employed? Yes No Professional Liability Does the Applicant have other professional errors or omissions or malpractice exposure? Yes No If yes, describe in full COVERAGES AND LIMITS REQUIRED PROPERTY: Building Equipment Stock Gross Earnings Profits Blanket Glass Detached Sign Satellite Dish FORM DED. LIMIT REQUIRED DO NOT USE CRIME: Broad Form M & S Inside & Outside LIABILITY: Comp. General Non-Owned Auto Tenants Legal Liability BOILER: Boiler Machinery

5 D E C L A R A T I O N I/We declare and warrant that after enquiry all statements and particulars contained in this Proposal and addenda are true and that no information whatsoever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this Proposal and should the above particulars alter in any way I/We will advise Underwriters as soon as practicable. I/We understand that failure to disclose any material facts that would be likely to influence the acceptance and assessment of the Proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into. I/We have been advised by the broker and consent to any information that may be perceived as personal information for collection, appropriate use, and disclosure of to third parties (PIPEDA). FOR AND ON BEHALF OF (Names of Proposes) Signature Date Name of Signatory (Please print) Position Should the client have a Website address, please fill in the space below Web Site Address: Brokerage Name: Individual Agents Name: Phone: Fax: Canada WorldWide (Calgary) Canada WorldWide (Toronto) Canada WorldWide (Simcoe) 100, st Street SW 106, 901 Yonge St 2 Norfolk Street Calgary, AB T2R 0V8 Toronto, Ont M4W 2H2 Simcoe, Ont N3Y 2V9 Toll Free: Toll Free: Toll Free: FAX: FAX: FAX: Canada Mondial (Montréal) Canada Mondial (Bedford) 300 Rue St.Sacrement Suite D Estrie PL Suite 106 Montréal, Que H2Y 1X6 Bedford, Que J0J 1A0 Toll Free: Toll Free FAX: Fax (450)

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